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3301 Exposition Blvd.

, 3rd Floor Santa Monica, CA 90404

INSANITY DATE AND WEIGHT DECLARATION Round 1: (Required)


Day 1 Weight Day 60 Weight Total Weight Loss Day 1 Date Day 60 Date Total Inches Lost

Round 2: (If applicable)


Day 1 Weight Day 60 Weight Total Weight Loss Day 1 Date Day 60 Date Total Inches Lost

Round 3: (If applicable)


Day 1 Weight Day 60 Weight Total Weight Loss Day 1 Date Day 60 Date Total Inches Lost

Round 4: (If applicable)


Day 1 Weight Day 60 Weight Total Weight Loss Day 1 Date Day 60 Date Total Inches Lost

Testimonial Information: (Required) Current Weight_______________________________________________ Date____________________________________

Signature_________________________________________________________________________________________________ Name____________________________________________________________________________________________________ Address__________________________________ City______________________ State_____________ Zip _________________ Telephone (_______)________________________ Email_________________________________________________________ Current Age_________________________________ Date of Birth__________________________________________________ Height_________________________________ Occupation________________________________________________________
Rev. 5/6/13

3301 Exposition Blvd., 3rd Floor, Santa Monica, CA 90404

GENERAL TESTIMONIAL RELEASE For valuable consideration, the receipt and sufficiency of which are hereby acknowledged and intending to be legally bound: 1. I hereby grant Beachbody, LLC, Team Beachbody, its parents, affiliates, subsidiaries, representatives, assigns, employees, officers and directors (collectively, Beachbody), and Beachbodys suppliers, distributors, advertising/promotion agencies and any persons or corporations acting under its permission or authority, or for whom it might be acting (collectively with Beachbody, Company) the right and permission to videotape, capture, record (including still and moving images, and sound recordings) and scan me or my minor child (Performance), including but not limited to any statement or endorsement (including any letter, or still, moving or sound recording) or any portions thereof (Testimonial) made by me or my minor child. I further grant Company a perpetual, worldwide, royalty free, unlimited, sublicensable and transferrable right and license to display, publish, modify, broadcast, publicly perform, reproduce, prepare derivative works of, distribute and/or otherwise use the Performance and/or Testimonial and any and all photographs, images, video, music, sound or other recording, writing, text and/or other information and content that I submit to Beachbody (including my name, image, likeness, fitness statistics and biographical information) (Content), in any media now known or hereinafter devised, in such manner, for such purposes and with such frequency as Company shall determine in its sole discretion, without further compensation or consideration to, or authorization by, me. 2. I acknowledge and agree that the Performance and Testimonial shall constitute the sole property of Beachbody, and along with the Content may be used and displayed by Company without restriction. I hereby waive all rights of inspection or approval with regard to any use of the Performance, Testimonial or Content by Company. I further acknowledge that nothing herein requires Company to make any use of the Performance, Testimonial or Content. 3. I affirm that (i) any statements or endorsement made by me in the Performance, Testimonial and/or Content are true, factually accurate and represent my honest and personal opinions, findings, beliefs, or experiences, (ii) I was not compensated in exchange for my endorsement (although I may have received a nominal reimbursement for my time and expenses), and (iii) no material connection exists between myself and Beachbody. 4. I expressly understand and agree that my activities related to and involvement in the Performance, and/or use of any Beachbody products may involve potentially dangerous and physical activities that may lead to personal and/or bodily injury, death, or damage to or loss of property or privacy. I hereby acknowledge and willingly accept these risks and agree to unconditionally release and hold harmless Company from and against all claims, suits, causes of action, costs, expenses or liability arising out of or related to my involvement in the Performance and/or use of any Beachbody products. 5. I represent and warrant that (i) the Content was or will be submitted voluntarily, (ii) I alone (and no other person or entity) own or control all rights (including without limitation all intellectual property rights) in and to the Content, and (iii) the Content and use thereof will not infringe the copyright rights or any personal, property or other rights of any third party. I hereby release, discharge, and agree to indemnify and hold harmless Company from and against any and all claims, suits, causes of action, costs, expenses or liability arising out of or related to its use of the Performance, Testimonial and/or Content, and/or related to my use of any Beachbody products. 6. I warrant that I am eighteen years old or older, and competent to contract in my own name, or if applicable, on behalf of my minor child. I agree that this Release shall be deemed to be entered into in the State of California, U.S.A. and shall be governed by and interpreted in accordance with the laws of the State of California, U.S.A. without regard to its choice of law provisions. In any action relating to this Release, I irrevocably consent to the exclusive jurisdiction of the State and Federal courts located in Los Angeles County, California and expressly waive any objection thereto. I waive all rights to a jury trial of any claim arising out of or relating to this Release, including the use of the Performance, Testimonial and/or Content. I have read this Release before signing below, and warrant that I fully understand its content. Signature__________________________________ Email_______________________________ Phone (___)______________ Name________________________________ Minor child (if applicable): ________________________ Date______________ Address________________________________________ City_________________________ State______ Zip _____________
Rev. 05/13

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